Abstract
Objective To clarify who generalist physicians are and what characterizes their practice.
Data sources MEDLINE, PsycInfo, SocINDEX, Embase, Ovid HealthSTAR, Scopus, and Web of Science.
Study selection Empirical studies (quantitative, qualitative, mixed methods) that described the attributes of generalist physicians across various disciplines in the clinical literature.
Synthesis A total of 262 studies from 25 countries met inclusion criteria. Forty-seven percent of studies lacked essential participant information. The remaining studies primarily framed generalism in terms of an absence of specialist training, reflecting a “deficit model” of care. We identified 4 archetypes of generalist practice: broad-based knowledge, generalism as adaptive expertise, generalism as integrative expertise, and generalism as interpretive expertise.
Conclusion Generalism lacks a consistent meaning across clinical disciplines in medicine. Four archetypes of practice are proposed to promote cross-disciplinary dialogue and guide the design of future health care systems and professional roles.
A robust workforce of medical generalists is frequently described as “the backbone” or “cornerstone” of any public health system.1 Traditionally, family physicians (general practitioners) were the quintessential generalists.2,3 Globally, however, generalism is increasingly endorsed across a range of specialties and health care settings, reflecting a growing recognition of its crucial role in addressing the complexity, uncertainty, and fragmentation characteristic of contemporary health care delivery.4-6 Medical education systems are increasingly tasked with producing more graduates oriented toward generalist careers.7-9 In Canada and the United Kingdom (UK), new medical schools have been established explicitly to train generalist practitioners. In the UK, the National Health Service (NHS) Long Term Workforce Plan6 explicitly emphasizes generalist training, anticipating the growing burden of multimorbidity and chronic disease in an aging population. Parallel to this, evolving models of care are extending generalist roles beyond traditional primary care settings: for example, the growing role of hospitalists or family physicians with focused areas of practice. These developments position generalism as a cross-disciplinary, boundary-spanning practice that transcends established specialty silos and enables clinicians to deliver more integrated, person-centred care across diverse clinical contexts.
Despite its increasing prominence, the practice of generalism remains elusive. It has been variously described as a philosophy of care4 encompassing the therapeutic doctor-patient relationship; contextual understanding of the patient within their familial and environmental milieu; continuity and coordination of care; and care with an emphasis on prevention and health promotion.10 Others characterize it more succinctly as whole-person care.11 However, such definitions, while conceptually rich, often fail to adequately articulate the core practices that define generalism as a clinical approach.12 Both medical students8,13 and experienced generalist clinicians11 report difficulty in conveying the fundamental nature of generalist practice.
A recent narrative review of international policy and mission statements—spanning both generalist and specialist domains—revealed substantial heterogeneity in how generalism is conceptualized.12 Some institutions frame it as a distinct form of clinical expertise grounded in breadth, while others view it as foundational knowledge applicable across various disciplines. This suggests a need to advance beyond the rhetorical commitment reflected in mission and policy statements to identify tangible strategies for embedding generalist principles into the fabric of clinical practice. As health care systems worldwide seek to address the consequences of fragmented and overly specialized care, a clearer understanding of how generalism is enacted in real-world settings becomes essential. Clarifying the characteristics of generalist clinicians and the nature of generalist practice is vital for informing the design of integrated, equitable, and responsive health care systems.
This review, therefore, aimed to develop a comprehensive understanding of how generalism is described and operationalized within the clinical literature. Specifically, we asked: How do empirical texts characterize generalists (the individuals engaged in generalist clinical work) and generalist practice (the nature of their work in practice)?
METHODS
We performed a mixed-studies systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guideline.14 The study protocol was published15 and registered with the International Prospective Register of Systematic Reviews.
Theoretical orientation
We used hermeneutics, the theory and practice of interpretation, to analyze the meanings attributed to words and descriptions of practice. Hermeneutics allowed us to explore how generalism is characterized within texts (eg, hidden curriculum, stigma). This approach assumes that no definition could be an objective, knowable structure and that we should “peer behind language”16 used to discuss generalism.
Search strategy
The search strategy was built with medical librarians. We searched MEDLINE, PsycInfo, SocINDEX, Embase, Ovid HealthSTAR, Scopus, and Web of Science databases. Search terms included generalism and generalist, and other terms representing general practice. To ensure that generalism within specialties was represented, we combined search terms for generalism with internal medicine, surgery, pediatrics, and psychiatry. The search strategy is available in Appendix 1 from CFPlus.*
Eligibility criteria
Table 1 reports inclusion and exclusion criteria. We focused on empirical studies to understand generalism as clinically enacted, instead of conceptual papers that describe how it should be done.
Inclusion and exclusion criteria
Study selection
Two reviewers independently reviewed abstracts. Items were included if they made explicit reference to generalism or generalists. The full text was retrieved if both reviewers could not reject a title or abstract with certainty. Next, 2 reviewers independently reviewed the full texts and discussed discrepancies with the team to reach a consensus on inclusion or exclusion.
Quality appraisal
Since our main aim was to review conceptualizations of generalism rather than empirical findings, we followed a precedent set by earlier researchers17 to include all relevant articles, irrespective of the strength of their methods.
Data extraction
We used a template in Microsoft Excel to organize and manage extracted data, and compiled tables describing study characteristics. To identify and describe generalists, we included studies where the terms generalism and generalist were used by paying attention to the stated and implicit meaning. We adopted a heuristic approach that regards linguistic expressions as having 2 aspects: intensions and extensions.18 Intensions are attributes, characteristics, ideas, or properties that a concept implies or suggests; extensions are objects (or classes of objects) to which a word or concept applies.18,19 To include a study, we required it to have either stated a substantive feature of generalism and specifically connected it to generalism (eg, “generalism involves patient-centred care”), or provided a clear example of generalists (eg “generalists are general practitioners [GPs] and other primary care physicians”).
Data synthesis
We used a convergent design to synthesize quantitative and qualitative study findings20 by analyzing qualitative and quantitative data separately before integrating them,17 and then bringing the 2 into conversation by representing quantitative data qualitatively. We achieved this by interrogating the data with questions such as the following: Who does this study involve? Who is described as a generalist? What characteristics of generalism are described?
Codes were generated inductively and then grouped into themes, refined through team meetings. We also searched the data for discordant findings to challenge and refine our interpretations. We drew on strategies suggested by Crabtree and Miller21 to promote team reflexivity and avoid premature anchoring. The study team consisted of family physicians (M.A.K., S.P., A.R., S.S.), a medical student (A.S.), and research assistants from Canada and the UK (S.C. and others). We also collaborated with patient partners during the project’s preparatory and analysis stages. To integrate the findings, we developed descriptive themes, which took account of similarities and differences across datasets; and analytic themes, resulting from an interpretive synthesis of perspectives on generalism present in the data.22
Ethics
This review did not require formal ethical approval as it draws on secondary data from published articles.
RESULTS
Of 6541 papers identified, 262 studies from 25 countries entered the final analysis (Figure 1). Table 2 summarizes their geographic locations and study designs.23-25 Most studies were quantitative: surveys (n=86 studies), retrospective reviews of administrative data (n=78), prospective cohort studies (n=11), statistical or economic modelling (n=9), and others (n=22). The rest of the studies were qualitative (n=33), reviews (n=13), mixed methods (n=6), and other types (n=4). Appendix 2, available from CFPlus,* details the aims, contexts, and participants (if known) of included studies.
Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram
Clinical disciplinary focus
Overall, 110 studies investigated generalism and generalist practice in medical specialties. Several additional studies crossed generalist and specialist boundaries by addressing career characteristics or medication use. Nearly half the studies included disciplines other than family medicine such as cardiology (n=24), women’s health including obstetrics and gynecology (n=19), pulmonology (n=14), pediatrics (n=14), and infectious disease (n=13). Surgical disciplines discussed included general surgery (n=2), otorhinolaryngology (n=7), and orthopedic surgery (n=5) (Appendix 3, available from CFPlus*).
Descriptive themes
Two broad descriptive themes—comparison and collaboration (Table 3)—were strongly represented. The comparison theme justified 1 approach against the other, often by referring to recruitment, working conditions, remuneration, or other structural workforce issues between generalists and specialists. The collaboration theme referred to the need for better communication, teamwork, and cooperation in both generalist and specialist practice. These themes were often in tension with each other within a single paper; for example, comparing outcomes as inferior or superior but ending with a call for greater collaboration, with less attention to how health care organizations and context shaped conclusions (eg, access to care, multimorbidity).
Descriptive themes by study type
Analytic themes
Characterising a generalist. Of the included studies, 122 (47%) did not define generalism or describe the nature of generalist participants. The remaining 140 studies (53%) provided greater detail: 72 identified participants by broad disciplinary affiliation (eg, family medicine, general internal medicine) and 68 of these further specified subdisciplines as generalist (eg, general cardiology, general pediatrics). Ninety studies defined generalists in deficit terms—as physicians lacking specialist training. Only 23 described positive attributes of generalism, including holistic care, patient-centred understanding, and sustained relationships.
Archetypes of generalism in practice. We identified 4 archetypes of generalist practice: generalism as breadth of knowledge, generalism as adaptive expertise, generalism as integrative expertise, and generalism as interpretive expertise. These categories represent distinct but sometimes overlapping conceptualizations of generalism (Appendix 4, available from CFPlus,* details illustrative quotes, references, and practice implications).
Generalism as breadth of knowledge: The most prevalent archetype, especially in United States (US)–based studies, defined generalism as broad-based knowledge; practitioners were those in general internal medicine, pediatrics, surgery, and generalists in subspecialties (eg, general neurology, radiology). These clinicians applied deductive reasoning and followed established diagnostic or treatment algorithms. Articles reported comparative outcomes, for example, in relation to adherence to guidelines, length of hospital stay, or prescribing practices. Articles written from this viewpoint often concluded that knowledge deficits led to suboptimal practice. Generalism was characterized by the presence or absence of knowledge. Perceived deficits could be addressed by filling knowledge gaps.
Generalism as adaptive expertise: Here, generalists were often family physicians or physicians working in primary care with additional procedural or clinical expertise (eg, in obstetrics, surgery, diabetes, or human immunodeficiency virus infection), often acquired to meet population needs—especially in underserved or rural settings. It also included physicians working in areas such as pediatrics or infectious disease who adapted their clinical practices in response to community needs, in particular the absence of subspecialty care. Generalism was characterized as flexible and responsive, adapting to local service gaps and often bridging primary and secondary care. In this type of generalist practice, the focus of the research studies was typically on service extension and its evaluation or comparison, with less emphasis on relational models of care.
Generalism as integrative expertise: This model was primarily associated with family medicine (North America), general practice (UK, Australia), hospitalists, geriatrics, and palliative care. In the US it also included community-based doctors working in primary care, such as internal medicine or pediatrics and other services where patients had repeated, and sometimes long-term contact with a physician or service. Emphasis was placed on care coordination, interprofessional communication, and the synthesis of specialist input within a broader biopsychosocial framework. Studies examined, for example, the role of teamwork, communication practices between primary and secondary care interfaces, and how to coordinate care. This archetype was oriented toward wellness, prevention, and continuity, drawing on but not confined to biomedical paradigms.
Generalism as interpretive expertise: This archetype emphasized relational, longitudinal care and inductive, person-centred problem solving. It treated generalist care as inherently interpretive and context-sensitive—a hermeneutic practice adapting, integrating, and implementing biomedical knowledge with a focus on understanding patients’ lived experiences as a holistic endeavour. This type of generalism was predominantly (but not exclusively) identified in qualitative studies based in family medicine from the UK.
“Ways of knowing” informs “ways of doing” generalism. These archetypes reflect divergent epistemologies—“ways of knowing” that shape “ways of doing” generalist care (Table 4). Most studies—especially US-based, quantitative research—positioned specialism as the norm, often treating generalism as the absence of further training (a deficit model). In contrast, a smaller body of qualitative, European, and UK literature portrayed generalism as a coherent, socially embedded model, emphasizing prevention, community engagement, and holistic care.
Different approaches to generalism and generalists
The concept of “complexity” illustrated this divergence. In broad knowledge-based generalism, complexity referred to biomedical severity requiring highly skilled specialists. In integrative and interpretive models, complexity was social and relational—managing multimorbidity within patients’ broader life contexts, requiring ecological awareness of individuals and communities.
Similarly, views on education diverged. Generalism emphasizing broad-based knowledge as the primary feature of generalism proposed discrete interventions to address gaps, such as formal training modules. Interpretive and integrative models emphasized ongoing, situated learning embedded in clinical practice—an iterative process linked to experience, context, and evolving care needs.
DISCUSSION
In an era when international health care systems struggle to recruit generalists, it is crucial that we value and recognize the range of expertise they bring. Our review highlights a persistent and counterproductive tension in the clinical literature.
The terms generalist and generalism are enacted across disciplines with differing epistemologies, shaping how generalist practice is applied, studied, and valued. While generalists and specialists are frequently framed as collaborators, generalism is more often constructed as a deficit rather than a distinct, skilled practice. This discourse positions generalism as “a lack of” rather than a specific way of practice. To reframe generalism and develop a cross-disciplinary dialogue around generalism, we identified 4 archetypes: knowing, adapting, integrating, and interpreting. Rather than reduce generalism into components, this spectrum of generalisms could be used to clarify assumptions and articulate understanding of generalism to support collaborative, patient-centred care—a practice of generalism that spans disciplinary boundaries.
Comparison with existing literature
The tendency to portray generalism as lacking scientific expertise has been documented in prior research.26,27 This contrasts with family medicine scholarship, which frames generalism as a mode of expertise grounded in inductive reasoning, contextual understanding, relational continuity, and holistic care.28-32 While broad knowledge is widely acknowledged as foundational to generalist practice, discussions of ways of knowing33,34 recognize knowledge as both objective and interpretive, embodied, and situated. The adaptive capacity of generalist clinical practice is central to several formal definitions; for example, both the Royal College of Physicians and Surgeons of Canada4 and the King’s Fund35 in the UK advocate for generalism as a means to meet community needs.
The COVID-19 pandemic further highlighted generalists’ flexibility as crucial to physician redeployment, as recognized in the NHS workforce plan.6 Adaptive expertise is also essential for addressing multimorbidity and service fragmentation.10,36 Cross-disciplinary generalism is increasingly evident in fields such as pediatrics, geriatric care, respiratory medicine, and cardiology. As the 2011 independent commission report of the Royal College of General Practitioners and the Health Foundation noted, most physicians lie along a continuum from generalism to specialism.5 Greater clarity is needed to articulate this continuum to inform role definition and collaborative practice, recruitment, and retention.
Strengths and limitations
This systematic review draws on a broad literature base spanning multiple disciplines and care settings. The inclusion of diverse methodologies allowed for the triangulation of quantitative and qualitative findings, enhancing the validity of our synthesis.
Initially, we considered using a priori definitions of generalism—primarily rooted in family medicine—as inclusion criteria. However, given the limited presence of such definitions in the wider literature, and endorsed by our patient advisors, we adopted a bottom-up approach. This decision allowed us to map the diversity of how generalism is understood and enacted beyond family medicine. Had we used fixed criteria, our final dataset would have been considerably restricted. Our approach thus “listened to the noise” of generalism in the literature, making visible its heterogeneity.
We limited our scope to studies from medical disciplines, excluding allied health professions. Given their growing role in health care, a review of how generalism is conceptualized across these groups would be a valuable complement.
Implications for research and practice
By framing generalism as a form of practice, we revalue a core mode of medical work. However, we also identified that “not all generalisms are equal.” Thus, when planning health care organization and workflows, articulating understanding of the nature of generalist practice could be an important starting point to avoid conflation about generalism across disciplines. Our archetypes offer “a world not of propositions but of practices”37—a constellation of ways in which generalism can be enacted and examined.37
Future research should be attentive to methodologic strengths and limitations in how generalism is studied. Building on consensus and the imperative for more generalists in the workforce to meet patient needs, researchers should in addition describe what they mean by generalism and include details of study participants. Comparative and qualitative approaches each illuminate different dimensions of generalist practice and should be used thoughtfully to advance both theoretical and empirical understandings.
Conclusion
“We learn who we are in practice, not in theory.”38 To support generalism as a care philosophy, we must move beyond simplistic binaries that oppose it to specialism.39,40 Focusing on what generalists do—knowing, adapting, integrating, and interpreting—and drawing on pragmatic examples from across the clinical literature offer a path toward clarifying and elevating generalist expertise in contemporary health care.
Footnotes
↵* Appendices 1 to 4 are available from https://www.cfp.ca. Go to the full text of the article online and click on the CFPlus tab.
Contributors
All authors contributed to conceptualizing and designing the study; to collecting, analyzing, and interpreting the data; and to preparing the manuscript for submission.
Competing interests
None declared
This article has been peer reviewed.
- Copyright © 2026 the College of Family Physicians of Canada
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